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SI Stipend Form

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					                                        Summer Institute
                                         Stipend Form

Please print clearly. Your reimbursement will depend on this form being filled out properly.

Name                                            Social Security #________________________

Email Address_______________________________________________________________

Mailing Address

City / State / Zip                                                    Phone #

Stipend Applying for: (Can only apply for one stipend.)

--------Gifted and Talented. A stipend of $200.00 is available for the first 15 registrants. To be
eligible for the stipend an individual must attend the Gifted and Talented-Level II training provided
at the Summer Institute (June 8 and 9).

_____Counseling. A stipend of $200.00 is available for the first 10 registrants. To be eligible for
the stipend an individual must attend the Transforming School Counseling in Montana-Level I
training provided at the Summer Institute on June 6.

Important Information: You will be notified by email if approved for the stipend. The stipend will
be paid after the conclusion of the Summer Institute and the completion and processing of the
necessary paperwork by the university. A signed W9 Form must be completed for the stipend to be
issued.




Participant Signature                                                 Date

Send Completed form to: John Keener, MCD, 1500 University Drive, Billings, MT 59101, or fax to
406-657-2313, or email to john.keener@msubillings.edu. Thank you.



For MCD use only

               Index #                   ____________
               Stipend                   $

               TOTAL                     $___________




MCD Authorized Signature                                       Date

				
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